American Journal of Sports

Medicine
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The Effects of Core Proprioception on Knee Injury: A Prospective Biomechanical-Epidemiological

Study
Bohdanna T. Zazulak, Timothy E. Hewett, N. Peter Reeves, Barry Goldberg and Jacek Cholewicki
Am. J. Sports Med. 2007; 35; 368 originally published online Jan 31, 2007;
DOI: 10.1177/0363546506297909

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The Effects of Core Proprioception
on Knee Injury
A Prospective Biomechanical-Epidemiological Study
Bohdanna T. Zazulak,*†‡§ DPT, MS, OCS, Timothy E. Hewett,||¶ PhD, FACSM,
§# ** §#
N. Peter Reeves, MSc, Barry Goldberg, MD, and Jacek Cholewicki, PhD
†
From the Department of Rehabilitation Services, Yale New Haven Hospital, New Haven,
‡
Connecticut, Department of Physical Therapy, Quinnipiac University, New Haven, Connecticut,
§
Department of Orthopaedics & Rehabilitation, Biomechanics Research Laboratory, Yale
||
University School of Medicine, New Haven, Connecticut, Sports Medicine Biodynamics Center
and Human Performance Laboratory, Cincinnati Children’s Hospital Research Foundation,
¶
Cincinnati, Ohio, the Departments of Pediatrics, Orthopaedic Surgery, and Biomedical
Engineering and Rehabilitation Sciences, University of Cincinnati College of Medicine,
#
Cincinnati, Ohio, the Department of Biomedical Engineering, Yale University, New Haven,
Connecticut, and **Yale University Health Services, Yale University, New Haven, Connecticut

Background: In sports involving pivoting and landing, female athletes suffer knee injury at a greater rate than male athletes.
Hypotheses: Proprioceptive deficits in control of the body’s core may affect dynamic stability of the knee. Female, but not male,
athletes who suffered a knee injury during a 3-year follow-up period would demonstrate decreased core proprioception at base-
line testing as compared with uninjured athletes.
Study Design: Cohort study (prognosis); Level of evidence, 2.
Methods: Study subjects were 277 collegiate athletes (140 female, 137 male) who were prospectively tested for core proprioception
by active and passive proprioceptive repositioning. Athletes were monitored for injury for 3 years. An ANOVA and multivariate logis-
tic regression were used to test whether core proprioception was related to knee injuries in athletes.
Results: Twenty-five athletes sustained knee injuries (11 women, 14 men). Deficits in active proprioceptive repositioning were
observed in women with knee injuries (2.2º) and ligament/meniscal injuries (2.4º) compared with uninjured women (1.5º, P ≤ .05).
There were no differences in average active proprioceptive repositioning error between injured men and uninjured men (P ≥ .05).
Uninjured women demonstrated significantly less average error in active proprioceptive repositioning than uninjured men (1.5º
vs 1.7º, P ≤ .05). For each degree increase in average active proprioceptive repositioning error, a 2.9-fold increase in the odds
ratio of knee injury was observed, and a 3.3-fold increase in odds ratio of ligament/meniscal injury was observed (P ≤ .01). Active
proprioceptive repositioning predicted knee injury status with 90% sensitivity and 56% specificity in female athletes.
Conclusions: Impaired core proprioception, measured by active proprioceptive repositioning of the trunk, predicted knee injury
risk in female, but not male, athletes.
Keywords: neuromuscular control; proprioception; ACL injury; gender differences; injury prevention

Female athletes have a greater susceptibility to knee
injury than male athletes.1,7,9,31,38 The combination of this
*Address correspondence to Bohdanna T. Zazulak, DPT, MS, OCS,
Yale New Haven Hospital, Yale Physician’s Building, 800 Howard Avenue,
New Haven, CT 06510; e-mail: bohdanna.zazulak@ynhh.org.
Presented at the interim meeting of the AOSSM, San Diego, February
2007.
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 35, No. 3
DOI: 10.1177/0363546506297909
© 2007 American Orthopaedic Society for Sports Medicine
greater susceptibility and a 10-fold increase in the female
sports population since the inception of Title IX has
resulted in a dramatic increase in the number of knee
injuries in women.31 In the United States, women and girls
sustain more than 30 000 anterior cruciate ligament (ACL)
injuries a year, with costs that may exceed $650 million
annually.29 The mechanism of ACL injury may include a
combination of the following components: valgus position-
ing of the lower extremity, relative extension with unbal-
anced weight distribution, and the center of the mass of
the body displaced away from the plantar surface of the

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368
Vol. 35, No. 3, 2007
foot that is flat on the ground.12,22 Proprioceptive deficits in
the body’s core may contribute to decreased active neuro-
muscular control of the lower extremity, which may lead to
valgus angulation and increased strain on the ligaments of
the knee.3,15,19,27,37
The core of the body includes the passive structures of
the thoracolumbar spine and pelvis and the active contri-
butions of the trunk musculature.35 The stability of the
body’s core is contingent on neuromuscular control of the
trunk in response to internal and external forces, including
the forces generated from distal body parts and from
expected or unexpected perturbations. Core stability, as
generally defined in sports medicine literature, is a foun-
dation of trunk dynamic control that allows production,
transfer, and control of force and motion to distal segments
of the kinetic chain.20 For the purposes of this study, a more
precise operational definition was developed. Core stability
was defined as the body’s capacity to maintain or resume a
relative position of the trunk after perturbation.
Deficits in core neuromuscular control may contribute
to unstable behavior and injury throughout all segments
of the kinetic chain.19 For example, abdominal muscle
fatigue appears to contribute to hamstring injuries.10 In
agreement with these findings, retrospective studies of
subjects with prior ankle sprains demonstrated a delay in
the onset of muscle activation of the gluteus maximus6
and the gluteus medius.2 Cholewicki et al8 observed
prospectively that delayed trunk muscle reflex responses
predicted low-back injuries in collegiate athletes. A
recent large prospective cohort study reported that
female athletes who subsequently suffered an ankle
injury demonstrated significantly greater body sway than
uninjured athletes.4 In contrast, predictors of injury in
male athletes were related to ankle range of motion and
not measures of proprioception.4 To date, no study has
established a correlation between core neuromuscular
control and knee injury.
Many athletic maneuvers, such as running, jumping,
and cutting, are inherently unstable and require neuro-
muscular control to maintain stability and improve per-
formance.25,26 Neuromuscular control of the trunk is based
on feedback control. The information concerning the state
of the system, such as position of each segment, is fed back
and used to modify the descending movement commands.
A host of sensory information is used to track the system
over time.11 Because control is driven by the estimated
state and not the true state, accuracy in representation
becomes an issue. A poorly represented system cannot be
controlled properly and at some point will become unsta-
ble. Consequently, impaired core proprioception may lead
to impaired control of the core, which in turn affects con-
trol of the knee and may lead to knee injury.
The purpose of this study is to identify potential factors
related to neuromuscular control of the trunk that predis-
pose athletes to knee injuries. We hypothesize that core
proprioception may play a role in dynamic stability of the
lower extremity and subsequent knee injuries. The first
hypothesis is that decreased proprioception will increase
knee injury risk. The second hypothesis is that propriocep-
tive deficits will predict knee injury risk in female athletes
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Core Proprioception on Knee Injury 369
but not in male athletes. Measurable deficiencies in core
proprioception could identify modifiable neuromuscular
risk factors that predispose athletes to knee injury.
METHODS
Subjects
Subjects were 277 Yale varsity athletes who volunteered
for the study. The participants comprised 140 women
(mean age, 19.4 yrs ± 1.0; mean height, 1.70 m ± 0.08; mean
body mass, 65.6 kg ± 8.7; mean body mass index, 22.6
kg/m2 ± 2.2) and 137 men (mean age, 19.3 yrs ± 1.8; mean
height, 1.83 m ± 0.08; mean body mass, 79.9 kg ± 11.9;
mean body mass index, 23.8 kg/m2 ± 2.8). Athletes were
tested at baseline and then followed for 3 years to track
any knee injuries sustained during that period. Before
experimental testing, every subject completed a detailed,
45-item questionnaire pertaining to personal data (height,
weight, and age), athletic experience, varsity level sport(s)
affiliation, and history of injury. None of the athletes
enrolled in the study had any history of knee injury. Knee
injury was defined as any ligament, meniscal, or
patellofemoral injury diagnosed by the university sports
medicine physician. Fractures and contusions were
excluded from the knee-injured athlete group. Knee
injuries were further subclassified as only ligament and/or
meniscal, and then only ACL injuries. Athletes were not
injured at the time of the test. All ligament and meniscal
injuries were confirmed by magnetic resonance imaging
(MRI). All subjects understood the experimental protocol
and signed the consent form, both of which were approved
by the Human Investigation Committee.
Proprioception Experiment
Core proprioception was evaluated using a previously
validated apparatus as described by Taimela et al (Figure
1).23,24,33 The apparatus was designed to produce passive
motion of the lumbar spine in the transverse plane. Subjects
were positioned on this apparatus so that the vertical pivot
axis extended through the L4/L5 vertebrae. The seat was
driven by a stepper motor at a steady, slow rate to minimize
tactile cueing. The contribution of the vestibular system was
eliminated since the upper body remained fixed to the back-
rest with a 4-point seatbelt and the lower body moved in the
plane parallel to the ground. Care was taken to eliminate
visual and auditory cues of the apparatus motion. Therefore,
this proprioception test focused mainly on the feedback from
muscular and articular mechanoreceptors of the trunk.
Subjects were initially rotated 20° away from the neu-
tral spine posture (at 2º per second) and briefly held in that
position for 3 seconds. In the passive test, the subjects were
slowly rotated toward the original position by the motor (at
1º per second). In the active test, the subject rotated him-
self or herself after the clutch was disengaged from
the motor drive. In both tests, the subjects stopped the
apparatus by pressing a switch when they perceived they
370 Zazulak et al
Figure 1. An apparatus for testing core proprioception. The
stepper motor drive can be disengaged for active reposition-
ing or engaged for passive repositioning.
were in the original, neutral position. Each subject per-
formed 4 practice trials before each test, 2 in each direction.
Subsequently, 5 randomized trials in each direction for
each test were performed.
Statistical Analysis
The average absolute repositioning errors from all 10 trials
were calculated. To determine the most appropriate set of
parameters for regression analysis, a 2-factor ANOVA with
Tukey’s post-hoc test was used to identify the measures
that differed significantly between the injured and unin-
jured athletes (P ≤ .05). The 2 factors were as follows: knee
injury versus no knee injury during the follow-up, and male
versus female. The dependent measures were the average
absolute error in active proprioceptive repositioning
(APR) and passive proprioceptive repositioning (PPR). A
prior analysis determined that 21 injuries were required to
achieve an adequate power of 0.8.
The reproducibility of both measures was tested by com-
puting intraclass correlation coefficients (ICC) (2, k)
between the averages of the first 5 trials and the last 5 tri-
als for each of the 277 subjects. The reproducibility of APR
and PPR was good as indicated by the ICC of 0.61 and 0.58,
respectively.
RESULTS
During the 3-year posttest follow-up period, 25 of the 277
athletes sustained knee injuries; 11 occurred in female sub-
jects and 14 in male subjects (Table 1). There were 16 liga-
ment and/or meniscal injuries; 7 occurred in women and 9
in men. Of these, 11 were ligament injuries. Six subjects
sustained ACL rupture, 4 females and 2 males. All ACL
injuries were confirmed by MRI.
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The American Journal of Sports Medicine
The ANOVA returned a significant interaction between
sex and knee injuries. Deficits in APR were observed in
female subjects with knee (2.2º) and ligament/meniscal
injuries (2.4º) compared with uninjured female subjects
(1.5º, P ≤ .05) (Figure 2). There was no significant difference
in average error in APR between injured male subjects
compared with uninjured male subjects (P ≥ .05) (Figure 2).
Interestingly, uninjured female subjects demonstrated sig-
nificantly less average error in APR than uninjured male
subjects (1.5º vs 1.7º, P ≤ .05) (Figure 2). No difference in
the average error in PPR was observed in knee injured ver-
sus uninjured athletes (P ≥ .05).
For each degree increase in average APR error, a 2.9-fold
increase in the odds ratio of knee injury (P = .005) and 3.3-
fold increase in the odds ratio of ligament/meniscal injury
were observed (P = .007). Active proprioceptive reposition-
ing predicted knee injury status with 90% sensitivity and
56% specificity, and ligament/meniscal injuries with 86%
and 61% specificity in female athletes (Table 2).
DISCUSSION
The findings of the current study demonstrate that
increased error in core proprioception is associated with
increased knee injury risk, which supports our first
hypothesis. The poor APR of the trunk in those female ath-
letes who subsequently suffered knee injuries supports our
second hypothesis and indicates that decreased core pro-
prioception could alter dynamic knee stability and may
explain the increased risk of knee injury during sports
activity in this high-risk population.
The proprioceptive deficits were observed in APR and not
PPR in the injured female athletes. The active (APR) and
Figure 2. Average absolute error in active proprioceptive
repositioning in female and male athletes who sustained or
did not sustain knee, ligament/meniscal, or anterior cruciate
ligament injury during the follow-up period (*P < .05). Error
bars designate standard error of the mean.
Vol. 35, No. 3, 2007 Core Proprioception on Knee Injury 371

TABLE 1
Description of the Injured Athletesa

Classification

Athlete Sex Injury Knee Lig/Men ACL

1 F ACL X X X
2 M ACL/MCL X X X
3 M PF X
4 M MCL X X
5 F ACL/MCL/MEN X X X
6 F PF X
7 M PF X
8 M LCL/MEN X X
9 M PF X
10 F PF X
11 F PF X
12 F PF X
13 F MEN X X
14 M PF X
15 F PF/MEN X X
16 M PF/MEN X X
17 M MEN X X
18 M MCL/MEN X X
19 F ACL/MEN X X X
20 F PF/MEN X X
21 M PF X
22 M MEN X X
23 M ACL/MEN X X X
24 M MCL X X
25 F ACL/MEN X X X
a
Lig/men, ligament and meniscus; MEN, meniscus; ACL, anterior cruciate ligament; F, females; M, males; MCL, medial collateral ligament;
PF, patellofemoral; LCL, lateral collateral ligament.

passive (PPR) tests differ with respect to the relative con-
tribution of the muscle receptor sensory input. In the
active test, trunk muscles generate the movement and
maintain fusimotor drive, therefore muscle spindle feed-
back is involved.11 However, during the passive test, when
muscles are not active, fusimotor activity and the sensory
feedback from muscle spindles are decreased. Therefore,
input from joint and cutaneous receptors likely plays a
greater role in sensory feedback.11 Hence, the level of input
from the muscle spindles during reproduction of the trunk
position likely differed between the active and passive
tests. The observed deficits in active proprioception may
have been translated to active athletic maneuvers associ-
ated with knee injuries.
The second hypothesis is that proprioceptive deficits
would predict knee injury risk in female athletes. We
hypothesized that this relationship would not be
observed in male athletes for several reasons. First, male
and female athletes have different ACL injury rates and
potentially different underlying mechanisms of ACL
injury.22 Second, our prior data demonstrated that body
sway was significantly worse in female subjects who suf-
fered ACL injury than in male subjects who sustained
ACL injury.16 In agreement with these earlier findings,
the female athletes who did not subsequently suffer
knee injury had significantly better trunk proprioceptive
ability than male athletes who did not go on to sustain
knee injury. In addition, the findings of Beynnon et al4
related to ankle injury indicate that women and men have
significantly different predictors of injury risk. Body sway
was reported to be a strong predictor of ankle injury risk
in female but not male athletes.4 There is no previously
published literature to the authors’ knowledge supporting
a relationship between decreased core proprioception and
knee injury. Our prospective study lends greater credence
to this association between decreased neuromuscular con-
trol of the body’s core and increased knee injury risk.
Hewett et al14,16 suggested that dynamic neuromuscular
training that enhances control of the body’s core would
improve dynamic stability of the knee joint. Proprioceptive
and neuromuscular control deficits are observed after ACL
rupture and well into the postoperative rehabilitation
period. Patients with ACL deficiency have impaired pos-
tural sway. Women with ACL-deficient knees and after
ACL reconstruction possess greater deficits in propriocep-
tion and neuromuscular control, as measured by postural
sway deficits, than their injured and reconstructed male
counterparts.16
The published literature referencing sex differences in
postural sway is equivocal, as 2 other studies reported pos-
tural sway on stable force platforms in healthy subjects
and observed no differences between sexes.5,13 In contrast,

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372 Zazulak et al
TABLE 2
Results of a Logistic Regression Analysis for Predicting Knee Injuriesa
Women
Knee Lig/Men
APR error (P value) 0.006 0.007
Odds ratio 2.91 3.31
Overall P value 0.005 0.007
Concordant observations 72.9% 74.0%
Sensitivity 90% 86%
Specificity 56% 61%
a
Lig/Men, ligament and meniscus; Lig, ligament; ACL, anterior cruciate ligament; APR, active proprioceptive repositioning.
Hewett et al16,17 examined single-leg balance of male con-
trol subjects compared with female control subjects on a
dynamic unstable platform and reported that the female
subjects performed significantly better than the male sub-
jects. However, in the subjects with ACL deficiency, the
men had significantly better preoperative performance
than the women.16,17 The finding of proprioceptive differ-
ences between sexes raises important issues. First, women
with intact knees have better single-leg balance than men
with intact knees. This difference is presumed to be attrib-
utable to the lower center of gravity in female control sub-
jects.21 However, after an ACL injury, women seem to
experience greater deficits in balance than men.16 In addi-
tion, the return of single-leg balance after ACL reconstruc-
tion is slower in women than in men.16
Hewett et al16 pose an important question of whether
female subjects with ACL ruptures possess deficits in bal-
ance or postural control before injury, which creates a pre-
disposition to injury, or the alternative possibility that
ACL injury is more traumatic to the proprioceptive sys-
tems of women than men. The findings of the current study
of better active proprioception in healthy female athletes
compared with healthy male athletes are consistent with
previous findings in healthy athletes, where women have a
superior ability to control body sway on a single limb com-
pared to men.16,17 Furthermore, the prospectively meas-
ured proprioceptive deficits exhibited by injured female
athletes support the theory that these deficits may predis-
pose the athlete to knee injury. The possibility that female
athletes with proprioceptive deficits possess a greater
propensity for knee injury suggests the need for pre-
screening before athletic participation to assess injury
risk. There is strong evidence that neuromuscular control
of the trunk and lower extremity can be improved with
neuromuscular training.18,28,30,34,36
Our study had a relatively low number of injuries, par-
ticularly of the ACL. This low subject number may have
potentially precluded our ability to detect poor APR as a
predictor of ligament and ACL injuries. However, the
power analysis was met for total injuries. A prior analysis
determined that 21 injuries were required to achieve an
adequate power of 0.8, whereas 25 injuries occurred in the
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The American Journal of Sports Medicine
Men
Lig ACL Knee Lig+Men Lig ACL
– – 0.914 0.852 – –
– – – – – –
0.913 0.851
38.1% 39.8%
62% 75%
53% 40%
study cohort of 277 subjects. Therefore, negative findings
relative to ligament and ACL injuries are not reported to
avoid potential beta-type error.
The tests of proprioception in the lumbar spine were con-
ducted under relatively artificial conditions and postures.
The pelvis was immobilized to isolate trunk movement.
Most clinical tests of postural sway and proprioception are
performed with the subject balancing on a single leg, which
involves all segments of the lower extremity and trunk. All
these factors are potential confounding variables relative
to isolated core proprioception in these clinical tests.32 In
contrast, the current reported method is a more direct
measure of core proprioception.
CONCLUSION
Decreased active core proprioception predicted knee injury
risk in female athletes. Athletes may be evaluated for
proprioceptive deficits before competition and targeted
for specific active neuromuscular training. Interventions
that incorporate core neuromuscular training, including
proprioceptive exercises, may significantly reduce knee
injury risk in this high-risk athletic population. Future
research should focus on neuromuscular training inter-
ventions specifically targeted to improve core propriocep-
tion. Well-controlled, prospective longitudinal studies of
defined populations of athletes should follow athletes
through multiple sports seasons to correlate changing core
proprioceptive profiles to injury risk.
ACKNOWLEDGMENT
This work was supported by National Institutes of Health
grants R01-AR049735-03 (TEH) and NIH grant R01-
AR46844 (JC) from the National Institute of Arthritis and
Musculoskeletal and Skin Diseases.
REFERENCES
1. Arendt E, Dick R. Knee injury patterns among men and women in col-
legiate basketball and soccer: NCAA data and review of literature. Am
J Sports Med. 1995;23:694-701.
Vol. 35, No. 3, 2007
2. Beckman SM, Buchanan TS. Ankle inversion injury and hypermobil-
ity: effect on hip and ankle muscle electromyography onset latency.
Arch Phys Med Rehabil. 1995;76:1138-1143.
3. Bendjaballah MZ, Shirazi-Adl A, Zukor DJ. Finite element analysis of
human knee joint in varus-valgus. Clin Biomech (Bristol, Avon).
1997;12:139-148.
4. Beynnon B, Vacek PM, Abate JA III, Murphy D, Paller D. A prospec-
tive study of risk factors for first-time ankle inversion ankle ligament
trauma. In: The Thirty-second Annual Meeting of the American
Orthopaedic Society for Sports Medicine. Hershey, Pa; 2006.
5. Black FO, Wall C 3rd, Rockette HE Jr, Kitch R. Normal subject postural
sway during the Romberg test. Am J Otolaryngol. 1982;3:309-318.
6. Bullock-Saxton JE, Janda V, Bullock MI. The influence of ankle sprain
injury on muscle activation during hip extension. Int J Sports Med.
1994;15:330-334.
7. Chandy TA, Grana WA. Secondary school athletic injury in boys and
girls: a 3-year comparison. Phys Sportsmed. 1985;13(3):106-111.
8. Cholewicki J, Silfies SP, Shah RA, et al. Delayed trunk muscle reflex
responses increase the risk of low back injuries. Spine. 2005;30:2614-2620.
9. Deitch JR, Starkey C, Walters SL, Moseley JB. Injury risk in profes-
sional basketball players: a comparison of Women’s National
Basketball Association and National Basketball Association athletes.
Am J Sports Med. 2006;34:1077-1083.
10. Devlin L. Recurrent posterior thigh symptoms detrimental to performance
in rugby union: predisposing factors. Sports Med. 2000;29:273-287.
11. Gandevia SC, McCloskey DI, Burke D. Kinaesthetic signals and mus-
cle contraction. Trends Neurosci. 1992;15:62-65.
12. Griffin LY, American Academy of Orthopaedic Surgeons. Prevention
of Noncontact ACL Injuries. Rosemont, Ill: Academy; 2001.
13. Hellenbrandt FA, Braun GL. The influence of sex and age on the pos-
tural sway of man. Am J Phys Anthropol. 1939;14:347-360.
14. Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in
female athletes: part 2, a meta-analysis of neuromuscular interven-
tions aimed at injury prevention. Am J Sports Med. 2006;34:490-498.
15. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neu-
romuscular control and valgus loading of the knee predict anterior
cruciate ligament injury risk in female athletes: a prospective study.
Am J Sports Med. 2005;33:492-501.
16. Hewett TE, Paterno MV, Myer GD. Strategies for enhancing proprio-
ception and neuromuscular control of the knee. Clin Orthop.
2002;402:76-94.
17. Hewett TE, Paterno MV, Noyes FR. Differences in single leg balance
on an unstable platform between female and male normal, ACL-
deficient, and ACL-reconstructed knees. In: The Twenty-fifth Annual
Meeting of the American Orthopaedic Society for Sports Medicine.
Traverse City, Mich; 1999.
18. Hewett TE, Stroupe AL, Nance TA, Noyes FR. Plyometric training in
female athletes: decreased impact forces and increased hamstring
torques. Am J Sports Med. 1996;24:765-773.
19. Hewett TE, Zazulak BT, Myer GD, Ford KR. A review of electromyo-
graphic activation levels, timing differences, and increased anterior
cruciate ligament injury incidence in female athletes. Br J Sports Med.
2005;39:347-350.
Downloaded from http://ajs.sagepub.com at COLUMBIA UNIV on November 13, 2008
Core Proprioception on Knee Injury 373
20. Kibler WB, Press J, Sciascia A. The role of core stability in athletic
function. Sports Med. 2006;36:189-198.
21. Klafs CE, Arnheim DD. Modern Principles of Athletic Training 7th
Edition. St Louis, Mo: C V. Mosby; 1989.
22. Krosshaug T, Nakame A, Boden B, et al. Mechanisms of ACL injury
in basketball: video analysis of 39 cases. Am J Sports Med. In
press.
23. Leinonen V, Kankaanpaa M, Luukkonen M, et al. Lumbar paraspinal
muscle function, perception of lumbar position, and postural control
in disc herniation-related back pain. Spine. 2003;28:842-848.
24. Leinonen V, Maatta S, Taimela S, et al. Impaired lumbar movement
perception in association with postural stability and motor- and
somatosensory-evoked potentials in lumbar spinal stenosis. Spine.
2002;27:975-983.
25. Loram ID, Kelly SM, Lakie M. Human balancing of an inverted pen-
dulum: is sway size controlled by ankle impedance? J Physiol.
2001;532:879-891.
26. Loram ID, Lakie M. Human balancing of an inverted pendulum: posi-
tion control by small, ballistic-like, throw and catch movements.
J Physiol. 2002;540:1111-1124.
27. Markolf KL, Burchfield DM, Shapiro MM, Shepard MF, Finerman GA,
Slauterbeck JL. Combined knee loading states that generate high
anterior cruciate ligament forces. J Orthop Res. 1995;13:930-935.
28. Myer GD, Ford KR, Brent JL, Hewett TE. The effects of plymometric
versus dynamic balance training on power, balance, and landing force
in female athletes. J Strength Cond Res. 2006;20:345-353.
29. Myer GD, Ford KR, Hewett TE. Rationale and clinical techniques for
anterior cruciate ligament injury prevention in female athletes. J Athl
Train. 2004;39(4):352-364.
30. Myer GD, Ford KR, Palumbo JP, Hewett TE. Comprehensive neuromus-
cular training improves both performance and lower-extremity biome-
chanics in female athletes. J Strength Cond Res. 2005;19:51-60.
31. NCAA. NCAA Injury Surveillance System Summary. Indianapolis, Ind:
National Collegiate Athletic Association; 2002.
32. Preuss R, Grenier S, McGill S. The effect of test position on lumbar
spine position sense. J Orthop Sports Phys Ther. 2003;33:73-78.
33. Taimela S, Kankaanpaa M, Luoto S. The effect of lumbar fatigue on
the ability to sense a change in lumbar position: a controlled study.
Spine. 1999;24:1322-1327.
34. Wilder DG, Aleksiev AR, Magnusson ML, Pope MH, Spratt KF,
Goel VK. Muscular response to sudden load: a tool to evaluate fatigue
and rehabilitation. Spine. 1996;21:2628-2639.
35. Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its
relationship to lower-extremity function and injury. J Am Acad Orthop
Surg. 2005;13:316-325.
36. Wojtys EM, Huston LJ, Taylor PD, Bastian SD. Neuromuscular adap-
tations in isokinetic, isotonic, and agility training programs. Am J
Sports Med. 1996;24:187-192.
37. Zazulak BT, Ponce PL, Straub SJ, Medvecky MJ, Avedisian LA,
Hewett TE. The effect of gender on hip muscle activity during landing.
J Orthop Sports Phys Ther. 2005;35:292-299.
38. Zelisko JA, Noble HB, Porter M. A comparison of men’s and women’s
professional basketball injuries. Am J Sports Med. 1982;10:297-299.